test Travel details AGE* TYPE OF PROGRAM ARRIVAL DATE DEPARTURE DATE Personal Details Title (Mr,Mrs,Miss,Ms etc...) * Passport No. * Passport country * Gender* MF First name* Family name* Chinese Name (if applicable) PinYin Birth date * Country of birth Nationality * Mother tongue Marital Status * Married Single Divorced Widow Home Address Postal Address (if different) Streeet * City* Region/Count * Postal Ccde* Country* Phone/Mobile* Email* Streeet City Region/Count Postal Ccde Country Phone/Mobile Email Personal Details Please give details of the last two educational establishments attended. Name Type of school (Primary school, High school,University,…) Address Integration date Leaving date Name Type of school (Primary school, High school,University,…) Address Integration date Leaving date Educational Qualifications Year Examining Body Exam Type School Subject Taken and Grades Please state your level of English. BeginerBasicIntermidiary Advance References Please give details of two people we might contact for references Title (Mr., Mrs., Ms., Dr., …) First Name Last Name Address Phone Title (Mr., Mrs., Ms., Dr., …) First Name Last Name Address Phone Sponsor details (who is going to pay for your fees?) Relationship First Name Last Name Address Phone Email - Please complete all sections and include the fees. - Places can only be reserved once full fees have been received. - Please note that registration & administration fees are not refundable. - Administration and registration fees GBP100.00 Residence Status Do you need a visa allowing you to stay in the U.K.? Yes No If Yes, please give details. Student Business Tourist Work Permit Visitor Others If Other, please explain. Have you ever been refused a visa to the U.K. YesNo If Yes, please give details. Health Do you have any medical condition? YesNo If Yes, please give details. You can refer to the list below Visual impairment Hearing impairment Disability affecting physical mobility Other (Asthma, Diabetes, Epilepsy,…) Emotional or behavioural disorder Mental illness Temporary disability after illness or accident Asperger's syndrom Moderate or severe learning difficulties Dyslexia Dyscalculia Other learning difficulties Have you received any special learning support at school? (eg. Have you had extratime in exams or a statement of educational need?) YesNo If Yes, please give details. Δ